Canadian surgeons are confident they could soon perform what has never before been attempted anywhere in the world — face transplants in children.

The highly complex surgeries, which have so far only been performed in adults, are now “technically feasible” in children and could be life transforming for those with devastating facial deformities and disfigurements for whom no other reconstructive alternatives exist, a team from Toronto’s Hospital for Sick Children reports in the journal, Plastic Surgery.

But the risky surgeries are fraught with profound ethical and moral challenges, including issues surrounding personal identity, informed consent and the possibility of “future resentment,” the team writes.

The “new face” would also have to come from a deceased child, raising questions about what would drive a family to make such a donation. Would a grieving mother donate her child’s face in the hope of one day “seeing” her child again, the authors ask.

SickKids and Toronto Western Hospital are in the final stages of securing Ontario health ministry approval for upper extremity transplantations — forearm and hands — in adults and children.

When that process began about six years ago, there wasn’t sufficient data to justify seeking approval for face transplants as well, said Dr. Ronald Zuker, a plastic and reconstructive surgeon at SickKids.

Now, more research articles have come out “that gives us further support for proceeding,” he said.

“I have every confidence that in the next relatively short period of time, we will have enough data about face transplants to go back to the ministry of health and say, we want to extend this to face transplants as well,” he said.

“But we want to do it very slowly, and very carefully, to make sure that everything works right and that we select the appropriate individuals for this.”

The transplants would require immune-suppressing drugs for life to reduce the risk of tissue rejection, potentially toxic medications that increase the risk of cancer.

Yet many children with severe disfigurements now undergo dozens of even the most advanced reconstructions and still suffer stigma and rejection, the authors write.

“Facial transplantation offers a chance — in a single stage — to alleviate much of that suffering with a single, albeit large and risky surgical procedure,” they said.

The donor and recipient would have to be matched closely for age, since the transplanted tissues and muscles would have to grow along with the child, and also for complexion and sex.

In some cases, the child is born missing a jaw, tongue or lower half of the face.

More than 25 adults worldwide have received face transplants since 2005, when the first partial transplant was performed on a woman in France whose face was mauled by a dog. The youngest known recipient is Ugur Acar, a 19-year-old Turkish man burned in a house fire when he was barely a month old. Three patients have died of complications related to their transplants.

Zuker said the procedures would cost roughly $250,000 each, not including the cost of lifelong immunosuppression therapy. Surgery could be offered to children who have suffered massive trauma to their faces from car crashes, burns, dog bites or cancer treatments where large tumours need be removed “leading to very serious facial disfigurement.”

Some children are born with rare facial deformities where segments of the face don’t develop properly and the child is born missing a jaw, tongue or lower half of the face.

But transplants can be exquisitely complex. “We want the face not only to be a piece of living skin. We want it to move,” Zuker said. “We want the muscles to move, we want the patient to be able to control the eyes, the nose, the mouth and to be able to speak properly and use the face to express emotions.”

All this requires nerves and muscles to be transplanted. A lack of circulation to the tissue, or severe infection, may mean the death of the patient.

But the operations could be life changing for “highly selected” children with severe scarring or deformities who are unable to socialize, “who are ostracized, who are unable to speak properly, who perhaps can’t show emotions through their face,” Zuker said. “These are the potential patients we would be looking to help.”

Unlike an organ transplant, a face transplant isn’t life saving, said Anna Pileggi, executive director of AboutFace a charitable organization that provides support for those living with facial differences.

In most cases, the child’s parents would be consenting to the transplant.

“This is going to be a huge burden for parents to try to figure out ‘do I do this or don’t I do this?’ ” Pileggi said.

“We know the devastation that people experience because they look so different,” she said. Children and adults are taunted, bullied, avoided and socially rejected, she said.

“But we know a lot of people who look really, really different, who overcome these challenges, and who go on to live full, productive lives,” she said.

“It’s not just the appearance that is going to make a life a happy life.”